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Audit of the Health Service Executive orthodontic referral pathway between 2009 and 2011 in the Dublin Mid-Leinster region.An audit was undertaken in 2009 to determine the success of the new national orthodontic referral protocol introduced to the Health Service Executive (HSE) in 2007 and operated in the Dublin Mid-Leinster HSE region. It was repeated in 2011 to determine if the HSE austerity measures have had a bearing on the orthodontic service performance in the Dublin Mid-Leinster HSE region. The audit also measured the success of referring practitioners in identifying the correct Index of Orthodontic Treatment Need (IOTN) classification of the patient. In the 2011 audit, the figures were broken down to identify the occlusal variables that caused dental practitioners most difficulties in identification. The audit demonstrates a good referral to assessment timeframe in 2009 (85-80% compliance for IOTN 5 and 4 within three to six months, respectively), which deteriorates significantly in 2011 (26-4% for IOTN 5 and 4 within three to six months, respectively). The ability of dentists to identify the correct IOTN classification was better in 2009 (60% correct) compared to 2011 (51% correct), but both figures fell below the audit standard of 75% of referrals with correct IOTN classifications. The IOTN occlusal dental health components most readily identified by referring practitioners and meeting audit standards were 5a (overjet >9mm), 5i (impacted teeth) and 5h (extensive hypodontia). The remaining occlusal dental health components in the HSE IOTN fell below the audit standard. The audit clearly identifies a requirement for a continued educational effort to maintain the HSE IOTN skill base in primary care, and a need for additional resources to manage the demand for orthodontic assessments.